Overweight females are prone to obesity-associated stress urinary incontinence (OA-SUI), but because the mechanisms underlying its pathology have not been well elucidated, no specific therapies for the condition have been developed. We have identified that dysfunction of urethral and pelvic floor striated muscles contributes to OA-SUI, as atrophy of skeletal muscle often occurs in obese people. Activating endogenous stem/progenitor cells to regenerate damaged muscles could comprise a useful therapeutic approach. However, systemic administration of stem cells or their activators can cause undesirable side effects in off- target organs or tissues. Localized administration of curatives does not resolve this problem, because injected stem or progenitor cells often migrate outside the target area. Our laboratory, which has focused on the biology of endogenous stem/progenitor cells for the past 13 years, is developing a non-invasive method that can recruit and retain these cells at selected sites, or activate them in situ. Our pilot experiments demonstrate that low-energy shock waves (LESW) at a very specific energy level activates urethral and pelvic floor muscle progenitor cells; they also down-regulate the muscle growth inhibitor myostatin. We hypothesize that by activating resident stem cells to grow new myofibers, LESW can reverse OA-SUI. To clarify mechanisms and identify potential clinical approaches, we are also investigating myostatin inhibition via a novel DNA-inhibiting method called clustered regularly interspaced short palindromic repeats interference (CRISPRi). We will use a rodent OA-SUI model to assess structural and functional outcomes of treatment with CRISPRi, LESW, or both, and compare the results with the effects of weight-loss (the first line treatment taken in the clinic). To elucidate how obesity affects the structure and function of the female urethral sphincter and pelvic floor muscles, the molecular mechanisms involved in activating its resident stem cells, and the impacts LESW has on their activation and differentiation. We will also establish the feasibility of inducing regeneration of this muscle by inhibiting myostatin signaling. These objectives lead us to propose the following Specific Aims: 1.To examine the effect of LESW and weight loss in a rat model of obesity-associated urethral and pelvic floor striated muscle dysfunction 2.To enhance the recovery of urethral sphincter and pelvic floor muscle by myostatin inhibition in rats with OA-SUI. 3. To identify the effects of dyslipidemia and hyperglycemia on muscle derived stem cells (MDSC) through the modulation of myostatin signaling, and its counteraction by LESW.